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J Am Coll Cardiol, 2008; 51:1369-1374, doi:10.1016/j.jacc.2007.11.071
© 2008 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: HYPERTROPHIC CARDIOMYOPATHY

Occurrence and Frequency of Arrhythmias in Hypertrophic Cardiomyopathy in Relation to Delayed Enhancement on Cardiovascular Magnetic Resonance

A. Selcuk Adabag, MD, MS*,*, Barry J. Maron, MD{dagger}, Evan Appelbaum, MD{ddagger},§, Caitlin J. Harrigan, BA§, Jacqueline L. Buros, BA§, C. Michael Gibson, MD, MS{ddagger},§, John R. Lesser, MD{dagger}, Constance A. Hanna, RN{dagger}, James E. Udelson, MD||, Warren J. Manning, MD{ddagger},§ and Martin S. Maron, MD||

* Division of Cardiology, Veterans Affairs Medical Center, Minneapolis, Minnesota
{dagger} Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
{ddagger} Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
§ PERFUSE Core Laboratory and Data Coordinating Center, Harvard Medical School, Boston, Massachusetts
|| Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts-New England Medical Center, Boston, Massachusetts.

Manuscript received August 2, 2007; revised manuscript received November 2, 2007, accepted November 26, 2007.

* Reprint requests and correspondence: Dr. A. Selcuk Adabag, Section of Cardiology (111 C), Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, Minnesota 55417. (Email: adaba001{at}umn.edu).

Objectives: Our aim was to determine whether myocardial fibrosis, detected by cardiovascular magnetic resonance (CMR), represents an arrhythmogenic substrate in hypertrophic cardiomyopathy (HCM).

Background: Myocardial fibrosis is identified frequently in HCM; however, the clinical significance of this finding is uncertain.

Methods: We studied prevalence and frequency of tachyarrhythmias on 24-h ambulatory Holter electrocardiogram (ECG) with regard to delayed enhancement (DE) on contrast-enhanced CMR in 177 HCM patients (age 41 ± 16 yrs; 95% asymptomatic or mildly symptomatic).

Results: Premature ventricular contractions (PVCs), couplets, and nonsustained ventricular tachycardia (NSVT) were more common in patients with DE than those without DE (PVCs: 89% vs. 72%; couplets: 40% vs. 17%; NSVT: 28% vs. 4%; p < 0.0001 to 0.007). Patients with DE also had greater numbers of PVCs (202 ± 655 vs. 116 ± 435), couplets (1.9 ± 5 vs. 1.2 ± 10), and NSVT runs (0.4 ± 0.8 vs. 0.06 ± 0.4) than non-DE patients (all p < 0.0001); DE was an independent predictor of NSVT (relative risk 7.3, 95% confidence interval 2.6 to 20.4; p < 0.0001). However, extent (%) of DE was similar in patients with and without PVCs (8.2% vs. 9.1%; p = 0.93), couplets (8.5% vs. 8.4%; p = 0.99), or NSVT (8.3% vs. 8.5%; p = 0.35).

Conclusions: In this large HCM cohort with no or only mild symptoms, myocardial fibrosis detected by CMR was associated with greater likelihood and increased frequency of ventricular tachyarrhythmias (including NSVT) on ambulatory Holter ECG. Therefore, contrast-enhanced CMR identifies HCM patients with increased susceptibility to ventricular tachyarrhythmias.

Abbreviations and Acronyms
  CMR = cardiovascular magnetic resonance
  DE = delayed enhancement
  ECG = electrocardiogram
  HCM = hypertrophic cardiomyopathy
  ICD = implantable cardioverter-defibrillator
  LV = left ventricular/ventricle
  NSVT = nonsustained ventricular tachycardia
  PVC = premature ventricular contraction
  ROC = receiver-operating characteristic
  SVT = supraventricular tachycardia


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 Proc. Natl. Acad. Sci. USAHome page
D. Wang, V. V. Patel, E. Ricciotti, R. Zhou, M. D. Levin, E. Gao, Z. Yu, V. A. Ferrari, M. M. Lu, J. Xu, et al.
Cardiomyocyte cyclooxygenase-2 influences cardiac rhythm and function
PNAS, May 5, 2009; 106(18): 7548 - 7552.
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 Circ Cardiovasc ImagingHome page
A. S. Flett, M. A. Westwood, L. C. Davies, A. Mathur, and J. C. Moon
The Prognostic Implications of Cardiovascular Magnetic Resonance
Circ Cardiovasc Imaging, May 1, 2009; 2(3): 243 - 250.
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 J Am Coll Cardiol ImgHome page
L. F. Tops and J. J. Bax
The Year in Imaging Related to Electrophysiology
J. Am. Coll. Cardiol. Img., April 1, 2009; 2(4): 498 - 510.
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 J Am Coll Cardiol ImgHome page
A. La Gerche, A. J. Taylor, and D. L. Prior
Athlete's Heart: The Potential for Multimodality Imaging to Address the Critical Remaining Questions
J. Am. Coll. Cardiol. Img., March 1, 2009; 2(3): 350 - 363.
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 Am. J. Roentgenol.Home page
A. Attili, G. C. Mueller, and S. M. Day
AJR Teaching File: Asymptomatic Man with Giant Negative T Waves on ECG
Am. J. Roentgenol., March 1, 2009; 192(3_Supplement): S57 - S61.
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 Circ Arrhythm ElectrophysiolHome page
S. Nazarian, D. A. Bluemke, and H. R. Halperin
Applications of Cardiac Magnetic Resonance in Electrophysiology
Circ Arrhythm Electrophysiol, February 1, 2009; 2(1): 63 - 71.
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 J Am Coll CardiolHome page
A. N. DeMaria, O. Ben-Yehuda, J. J. Bax, G. K. Feld, B. H. Greenberg, W. Y.W. Lew, J. A.C. Lima, A. S. Maisel, S. M. Narayan, D. J. Sahn, et al.
Highlights of the Year in JACC 2008
J. Am. Coll. Cardiol., January 27, 2009; 53(4): 373 - 398.
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 J Am Coll CardiolHome page
A. Rudolph, H. Abdel-Aty, S. Bohl, P. Boye, A. Zagrosek, R. Dietz, and J. Schulz-Menger
Noninvasive Detection of Fibrosis Applying Contrast-Enhanced Cardiac Magnetic Resonance in Different Forms of Left Ventricular Hypertrophy: Relation to Remodeling
J. Am. Coll. Cardiol., January 20, 2009; 53(3): 284 - 291.
[Abstract] [Full Text] [PDF]

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 J Am Coll CardiolHome page
M. L. Chuang and W. J. Manning
Left Ventricular Hypertrophy and Excess Cardiovascular Mortality: Is Late Gadolinium Enhancement the Imaging Link?
J. Am. Coll. Cardiol., January 20, 2009; 53(3): 292 - 294.
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 CirculationHome page
M. S. Maron, J. J. Finley, J. M. Bos, T. H. Hauser, W. J. Manning, T. S. Haas, J. R. Lesser, J. E. Udelson, M. J. Ackerman, and B. J. Maron
Prevalence, Clinical Significance, and Natural History of Left Ventricular Apical Aneurysms in Hypertrophic Cardiomyopathy
Circulation, October 7, 2008; 118(15): 1541 - 1549.
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 HeartHome page
P Elliott and P Spirito
Prevention of hypertrophic cardiomyopathy-related deaths: theory and practice
Heart, October 1, 2008; 94(10): 1269 - 1275.
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 J Am Coll CardiolHome page
A. Dhoble, S. R. Punnam, and G. S. Abela
Likelihood of Ventricular Arrhythmias Due to Myocardial Fibrosis in Hypertrophic Cardiomyopathy as Detected by Cardiac Magnetic Resonance Imaging
J. Am. Coll. Cardiol., September 9, 2008; 52(11): 969 - 969.
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 J Am Coll CardiolHome page
A. S. Adabag, B. J. Maron, E. Appelbaum, C. J. Harrigan, J. L. Buros, C. M. Gibson, J. R. Lesser, C. A. Hanna, J. E. Udelson, W. J. Manning, et al.
Reply
J. Am. Coll. Cardiol., September 9, 2008; 52(11): 969 - 970.
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 J Am Coll CardiolHome page
N. Reichek and D. Gupta
Hypertrophic Cardiomyopathy: Cardiac Magnetic Resonance Imaging Changes the Paradigm
J. Am. Coll. Cardiol., August 12, 2008; 52(7): 567 - 568.
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 J Am Coll CardiolHome page
S. Nazarian and J. A.C. Lima
Cardiovascular Magnetic Resonance for Risk Stratification of Arrhythmia in Hypertrophic Cardiomyopathy
J. Am. Coll. Cardiol., April 8, 2008; 51(14): 1375 - 1376.
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